VictoriaF wrote:. . .You can tweak the labels, their meanings, and the corresponding numbers. You can also assign different weights to the categories of Wealth and Work Environment. The value of this process is not as much in that it will provide The Number, as that it will give you more clarity in what you really want.

This decision making approach is useful for all life changing decisions, including selection of the profession, educational path, employers, and dating and marriage.

This is a terrific decision-making process. You can add more options to consider (eg, work part-time, volunteer in area of interest (low-income or 3rd world areas), build other sources of retirement income) and/or more categories to consider (although the original question is only comparing finances and job satisfaction, but maybe location, reputation, impact on family could be considered). Many of us have made lists of pros and cons, but not weighted the importance of each item.

Thank you, Celia.

To clarify, the example I have provided earlier included only impacts and probabilities of various outcomes. If weights were used they would be added to the impacts. When weights are not explicitly applied, all criteria are implicitly given equal weight.

Victoria

WINNER of the 2015 Boglehead Contest. |
Every joke has a bit of a joke. ... The rest is the truth. (Marat F)

I recommend that you read a book So Good They Can't Ignore You: Why Skills Trump Passion in the Quest for Work You Love by Cal Newport. The book provides several important messages. The ones particularly relevant to you are:

1. Passion is overrated. Many people live their entire lives in misery of the eternal search of an elusive passion.
2. Abandoning a solid but boring job to pursue a passion, without adequate preparation, ends badly.
3. When one becomes really good in what he does, he becomes so valuable that he can dictate his rules.
4. Transitioning to new jobs and ways of life works out best when it builds on one's strengths.

I don't know which of these principles are most applicable to your case. It's likely a combination of all of them. If you decide to read the book, you will have Aha moments that may help you with your ultimate decision.

Good luck,
Victoria

WINNER of the 2015 Boglehead Contest. |
Every joke has a bit of a joke. ... The rest is the truth. (Marat F)

I recommend that you read a book So Good They Can't Ignore You: Why Skills Trump Passion in the Quest for Work You Love by Cal Newport. The book provides several important messages. The ones particularly relevant to you are:

1. Passion is overrated. Many people live their entire lives in misery of the eternal search of an elusive passion.
2. Abandoning a solid but boring job to pursue a passion, without adequate preparation, ends badly.
3. When one becomes really good in what he does, he becomes so valuable that he can dictate his rules.
4. Transitioning to new jobs and ways of life works out best when it builds on one's strengths.

I don't know which of these principles are most applicable to your case. It's likely a combination of all of them. If you decide to read the book, you will have Aha moments that may help you with your ultimate decision.

For me, financial independence was a life changing mental milestone as it allowed me to take >100% income risks. However, in reality it did not significantly change my day to day activity... I have been lucky enough to be "fishing on the beach" all my life.

As I read your post, it sounded like pediatric ER medicine is your "fishing". If so, I encourage you to follow it... even if it turns out that it is not... then IMHO you should have no regrets but keep searching. I say this in the context that you will clearly not starve while you search:-)

For me, financial independence was a life changing mental milestone as it allowed me to take >100% income risks. However, in reality it did not significantly change my day to day activity... I have been lucky enough to be "fishing on the beach" all my life.

As I read your post, it sounded like pediatric ER medicine is your "fishing". If so, I encourage you to follow it... even if it turns out that it is not... then IMHO you should have no regrets but keep searching. I say this in the context that you will clearly not starve while you search:-)

Happy Hunting!

To me pediatric emergency is a passion but it's first of all a mean to something bigger. When I ask myself what I really want in life for self fulfillment I come up with one and the same answer: Time. Time to do the many things that I enjoy doing; Time for my hobbies, family, time to do nothing or to do everything. And I reached the conclusion that working 2 days a week and enjoying 5 days a week of "free" Time is a great deal, a great goal to seek.

if I get there I may not need to retire ever as for me working 2 days a week is optimal indefinitely. To me, the concept of retirement as the end of work derives from the industrial revolution, from jobs that were physically and mentally demanding, unrewarding, very often hazardous to your health. If you are lucky enough to do something that you love and at the same time you have time to enjoy life, why should you ever quit if you are healthy enough to do it?

So Gen peds vs peds EM is part of a journey that seeks Time. I can only enjoy Time if I can have a fulfilling 2 days a week job.

A couple of years ago I considered changing my career field to pursue a passion of mine. In my case I really wanted to be a Physician Assistant. It required me to go back to school, but that wasn't the big deterrent as I had the funds to pay for the school and not struggle financially while attending school. I decided not to pursue a PA career because I once heard someone say the enemy of good is trying to be great. In my case I have a good job with good pay and benefits and if I stick with the job and with my savings habits I will reach my financial goals in 10 years which would allow me more time to pursue and do other things I deem important in life. I've decided I will take the good situation were I have job satisfaction over what could potentially be a great situation as a PA. The truth is I'm not sure if being a PA would have been a great job situation. I do know I have a good situation now so why walk away. You seem to be a good situation with your current job. I would stay the course.

Streptococcus wrote:if I get there I may not need to retire ever as for me working 2 days a week is optimal indefinitely. To me, the concept of retirement as the end of work derives from the industrial revolution, from jobs that were physically and mentally demanding, unrewarding, very often hazardous to your health. If you are lucky enough to do something that you love and at the same time you have time to enjoy life, why should you ever quit if you are healthy enough to do it?

Modern jobs can be even more hazardous to one's health than industrial-age jobs. 24-hour online presence, meetings and teleconferences, sitting all day long, short sleep, long commute--all these suck out joy from even the most rewarding and well compensated careers. In every job, there is a non-trivial risk that the circumstances will change for the worse and the overall sentiment will turn negative. Thus, being able to retire is a very valuable option, even if you never develop the need to exercise it. And you don't know which way it will be for you. For example, Letsgobobby's father did not have to retire, but Letsgobobby might.

The time with the family is a definite advantage of a part-time job. But there is more to life than having more time with the family. You may want to explore the world. You may develop interests that would take you to remote places for long periods of time. A full retirement, in contrast with part-time retirement, provides you with the freedom to do the things that you are truly interested in.

Among my Bogleheads role models are Raybo and Kramer. Check out their messages about bicycling around the world and living around the world, respectively. For both of them, retirement has opened opportunities unimaginable by those who are holding on to temporary and part-time jobs. Raybo's and Kramer's way requires courage and preparedness to cut all the strings at the right time.

Victoria

WINNER of the 2015 Boglehead Contest. |
Every joke has a bit of a joke. ... The rest is the truth. (Marat F)

johnep wrote:It seems you have two good options. Whichever you choose, you will be fine. However, you have strong preference for emergency medicine. To pursue that will delay your reaching your investment goal by 3 to 5 years. Which is most important to you? It sounds like EM is but you must decide. I would advise you to take a long term view of this to decide which is best. How will you feel in 10 to 15 years with each of these choices. Once you decide, go for it and do not look back.

"The two most important days in someone's life are the day that they are born and the day they discover why." -John Maxwell

Another physician here. In my opinion, unless one is >80% sure they will be happy with such a move it isn't worth considering. I don't see how you could even put anything close to that number in you planning as you are considering a different field (in personality, work schedules, etc...) then you currently have without any direct experience to confirm it is what you think it will be like if you made the switch.

If it was me I would take the "bird in the hand" and go with it. You are doing great following your IPS so why not just follow it. That is why we make IPS, don't we, as a financial map to our success.

If you are happy with your current job then why take a chance you may put years into going into a field you might not like in the end? Finding something interesting is much different then doing it for a living. I love investing, but would never consider that as a real career plan for many reasons, for example.

If you do decide to seriously consider making the switch I would DEFINETLY suggest doing a couple of shifts with some ER docs to see if it is what it is all cracked up to be. I trained at big places and live in a metro. area and must say the ER docs job is rather boring. Anything good the trauma surgeon and anesthesia guys come in and do all the cool stuff. I often feel bad for them as they are the true dumping grounds of many physicians and are under the thumb of hospital administrations.

Good luck.

"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” |
-Jack Bogle

celia wrote:My spouse thinks that I should go to fellowship because we will be fine anyways, even if the goal is delayed. That is true, but money made today has more value than money made in the future. I am not likely to have the same income (300-400K/year) in the next 4-5 years. The investor in me sees many years of lost investing opportunities. But the physician in me sees a great career opportunity.

Fellow late bloomer here (PhD plus postdoc). At 40 we were well on our way to building up assets, though still in the early days; meanwhile the career I'd loved for so long had taken a turn, and was beginning to be less satisfying. My spouse took a risk and made a career shift; I did not. We're 53 now, and we have more than exceeded our financial goals, largely due to my spouse more than me.

Your spouse can most likely see you more clearly than you can see yourself. I would take the fellowship. 40 is young - I'd love to be able to go back to 40 and change my path. The time value of money isn't worth your life, and you can easily afford 4-5 years of opportunity cost.

Dear Bogleheads,
Thank you for all your posts. They are exactly what I needed. I have 4 days to make the final decision and for some unexpected reasons, this has been the hardest decision that I ever made in my life. And getting different perspectives from dozens of smart people like you is priceless.

celia wrote:My spouse thinks that I should go to fellowship because we will be fine anyways, even if the goal is delayed. That is true, but money made today has more value than money made in the future. I am not likely to have the same income (300-400K/year) in the next 4-5 years. The investor in me sees many years of lost investing opportunities. But the physician in me sees a great career opportunity.

Fellow late bloomer here (PhD plus postdoc). At 40 we were well on our way to building up assets, though still in the early days; meanwhile the career I'd loved for so long had taken a turn, and was beginning to be less satisfying. My spouse took a risk and made a career shift; I did not. We're 53 now, and we have more than exceeded our financial goals, largely due to my spouse more than me.

celia wrote:My spouse thinks that I should go to fellowship because we will be fine anyways, even if the goal is delayed. That is true, but money made today has more value than money made in the future. I am not likely to have the same income (300-400K/year) in the next 4-5 years. The investor in me sees many years of lost investing opportunities. But the physician in me sees a great career opportunity.

Fellow late bloomer here (PhD plus postdoc). At 40 we were well on our way to building up assets, though still in the early days; meanwhile the career I'd loved for so long had taken a turn, and was beginning to be less satisfying. My spouse took a risk and made a career shift; I did not. We're 53 now, and we have more than exceeded our financial goals, largely due to my spouse more than me.

You had TWO people making serious money. He does not.

Not for a while now - I fizzled out and never got back on track. Our financial goals were more than met because my spouses gamble paid off, but I would happily trade that for the chance for a do-over. And so would he. The portfolio is nice to have but does not bring much satisfaction.

You have to decide if this is a good life decision. I can't help there.

The financial part is easy. Try living on 55K/12 for a few months and see how it goes, before you quit. With 4 days left this is not feasible, but maybe you should postpone if you are not 120% sure about this.

I'm sorry, but anywhere you work will eventually lose its charms. I was an RN for a while and moved easily among many specialties without additional years of training, just for a change. Each one became routine and I'd move on. I remember in my first specialty a nurse saying she left peds when she was no longer moved by a child dying. Eventually I moved into IT (with years of training) where I repeated the same pattern until age 52.

Streptococcus wrote:Dear Bogleheads,
Thank you for all your posts. They are exactly what I needed. I have 4 days to make the final decision and for some unexpected reasons, this has been the hardest decision that I ever made in my life. And getting different perspectives from dozens of smart people like you is priceless.

You do not have 4 days to make the final decision. That is when the rank list for this application cycle is due (thank you Google), and there is always next year. If you are wavering this much I would not submit a rank list for what will be a binding contract. Do not let an artificially self-imposed deadline dictate the rest of your life.

Looking back through the posts, I think I have counted 5 of your physician colleagues warning you against this change, and 1 physician colleague supporting it.

interesting thread. You do sound happy in your current job. Seems like a big risk.

I will be surprised if you find the Peds EM compensation or schedule to be a dramatic improvement over your current practice. My advice - don't base this decision primarily on lifestyle or money. I think both will be a wash.

The real risk here is you don't end up liking Peds EM as much as you think you will. Hard to predict that base on what's written in this thread.

If you can live happily on $55k, why not just shift to your 2days/week schedule right now? That should be making you $120k+ (based on $300k+ for 5 days/week), so you can still save 50% of your salary pretty easily and live the life you say you have as an ultimate goal.

Streptococcus wrote:Dear Bogleheads,
Thank you for all your posts. They are exactly what I needed. I have 4 days to make the final decision and for some unexpected reasons, this has been the hardest decision that I ever made in my life. And getting different perspectives from dozens of smart people like you is priceless.

You do not have 4 days to make the final decision. That is when the rank list for this application cycle is due (thank you Google), and there is always next year. If you are wavering this much I would not submit a rank list for what will be a binding contract. Do not let an artificially self-imposed deadline dictate the rest of your life.

Looking back through the posts, I think I have counted 5 of your physician colleagues warning you against this change, and 1 physician colleague supporting it.

I said 4 days because If I dont do the fellowship this year, I will move on my current path and not look back.

TomTX wrote:If you can live happily on $55k, why not just shift to your 2days/week schedule right now? That should be making you $120k+ (based on $300k+ for 5 days/week), so you can still save 50% of your salary pretty easily and live the life you say you have as an ultimate goal.

Living on 55K wont be easy but to tell the truth, it would only be the first year. I have a lot of free time during the fellowship and moonlighting is highly encourage. Some fellows moonlight 4 shifts a month in other EDs raising their salary to ~90k a year. This is doable because there are only 4 months with 12 shifts. The other months are elective or research months with only 4-5 shifts.
But I understand those, notably physicians, who point out that leaving a 350k and rising situation to a 55k and rising situation is a bad idea. There are many pros and cons on both sides.
One of the thing I may have a harder time with if I swith to EM is the bureaucratic/administrative aspect of the job will be amplified. Right now, although I'm hospital based, I basically my job as a private property. I can open an hour or 2 earlier and close earlier and pick the staff I want to work with. There will be no such flexibility as an EM. On the other hand I work/live in a small town and I'm not really a small town type of person.

So the bottom line here is that I may make my life more complicated than it has to be. But whatever I decide, I will be happy with it. I'm usually a happy kid and i dont get into ulcer-creating-regret type of situations. If i make a mistake, I will embrace the pros of the mistake and be happy with them.

Streptococcus wrote:One of the thing I may have a harder time with if I swith to EM is the bureaucratic/administrative aspect of the job will be amplified. Right now, although I'm hospital based, I basically my job as a private property. I can open an hour or 2 earlier and close earlier and pick the staff I want to work with. There will be no such flexibility as an EM. On the other hand I work/live in a small town and I'm not really a small town type of person.

Oh man I don't think there should be any thoughts of switching. There is NO price on being your own boss especially if you want to have the freedom of changing your schedule whenever you want. Working in the ER, anesthesia, rads, path, hospitalists are ALL under the thumb and mercy of the administration. Many of these groups think they have freedom, but in reality only can do what the admin. will allow. They are always cognizant they can be replaced at any time as none of these fields bring patients, i.e. customers to the hospital themselves.

I think this is a MAJOR factor you need to consider what to do. I went solo recently after being employed and must say there is NO price you can place on professional freedom. You can work as hard or as little as you want going forward when you hit the "number" as you discussed. You likely will have little control of when you can cut down being part of a bigger group.

Good luck.

"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” |
-Jack Bogle

Most respondents seem to be insinuating your dilemma appears to be more personal than financial. You are clearly an "overachiever" within your own specialty.
Certainly whatever your decision, you will find a way to remain financially solvent, and your current skills will always offer a roof over your head.

You seem to be simultaneously trying to embark on your next ambition, and planning for a new life deriving meaning from the immediate, rather than from the future.

It is familiar territory, and in my opinion can be expected to take years to unfold with reflection. Perhaps asking your fellow bogleheads, and focusing on the financial aspects, is not really getting to the heart of it.

But since you are inquiring in this manner, my two cents suggest:

If you are unhappy, I see no reason not to change now. Or if change does not appear to address it, reflect on the true foundation for your unhappiness.
But you don't sound unhappy. But I do still hear a tone of ambition.

From a financial standpoint, consider holding on to your current practice for the time being, and selling your practice when the time is right. There can be a lot of opportunity here, and switching to a fellowship now would likely exclude you from your very best financial opportunities in medicine. It will not be getting any better - but that does not mean you won't enjoy the challenge.

anonyvestor wrote:Most respondents seem to be insinuating your dilemma appears to be more personal than financial. You are clearly an "overachiever" within your own specialty.
Certainly whatever your decision, you will find a way to remain financially solvent, and your current skills will always offer a roof over your head.

You seem to be simultaneously trying to embark on your next ambition, and planning for a new life deriving meaning from the immediate, rather than from the future.

It is familiar territory, and in my opinion can be expected to take years to unfold with reflection. Perhaps asking your fellow bogleheads, and focusing on the financial aspects, is not really getting to the heart of it.

But since you are inquiring in this manner, my two cents suggest:

If you are unhappy, I see no reason not to change now. Or if change does not appear to address it, reflect on the true foundation for your unhappiness.
But you don't sound unhappy. But I do still hear a tone of ambition.

From a financial standpoint, consider holding on to your current practice for the time being, and selling your practice when the time is right. There can be a lot of opportunity here, and switching to a fellowship now would likely exclude you from your very best financial opportunities in medicine. It will not be getting any better - but that does not mean you won't enjoy the challenge.

Thank you for the great post. I think you hit quite a few nails in the head. Ambition is a big drive in my decision process. I still have a hard time reconciling with the idea of quitting at the general pediatrician stage.
But I think I'm getting there and I will let you guys know about the final decision.

Forgive me, I haven't read the other replies, so I may be repeating.
#1 what's your social situation? do you have a spouse, children, etc? 55k per year simply won't cut it, unless your spouse is earning the extra 250K difference, or at least some reasonable fraction of it thereof.
#2 ok, you love the ER. I get it. How old are you. ER is a young man's game, and you WILL burn out from that also. Yes, you'll do three 12's and then have the rest of the week to do what you want, but just look at the whole picture.
#3 You've got a great practice. You're making over 300K, have great relationships with your patients and have a low liability. I really don't get the trade here. You want to exchange lesser pay, higher liability, and a shorter career for what you have. Please, please someone explain this to me.
#4 OK, I get it. You love the adrenaline rush of the ER. Just beware #2 above, and if you really seek an adrenaline rush, do some extreme sporting.
I WOULD NOT make this move. Period.
P.S. I did internal medicine for three years, then went into anesthesia, which was 3 more years. The difference is that I wasn't earning any money other than a resident's salary, so I was only going to go in one direction. You'll also lose 750K in earnings and in potential investment accumulations.
Just a bad, bad plan. Stick to what you've got. The grass isn't always greener.
OK, sermon finished.

Streptococcus wrote:
I said 4 days because If I dont do the fellowship this year, I will move on my current path and not look back.

How much could you have possibly wanted to make the change if you're not willing to wait even one more year to make it? It sounds to me like your artificial "now or never" deadline was a way of talking yourself out of making the change without actually having to own the decision.

Just a follow up point I neglected to mention. From a financial point of view, 'doc in the box' urgent care centers are springing up all over the place with board certified ER docs manning them, who are on salary to the parent company that franchises the urgent care center.
So, you may be severely financially limited in exactly how much money you can make. I can guarantee you these centers are not going to give away anything. I've seen this occur in other specialties, including my own, where we work for either salary, or get a set fee per case, or some other permutation of this.
ALL of medicine is heading in this direction, so it's quite possible that your 300K peds practice may also go the way of the dinosaur. But, just from what's been posted here, I can say that, from the little I know, you seem to be making about twice the norm for a pediatrician. I'd hold onto that with both hands for as long as I could. And eventually, when you're ready, you can sell your practice to a hospital, which is also the way things are going, and gain some serious coin.
For fun, instead of ER, why not try going to a third world country and donating your services with your current skill set. It's tremendously satisfying to be freed of the red tape that exists here and simply enjoy the wonderful feeling that washes over you when you give of yourself to those who truly are less fortunate. It's paid for in smiles, and the village warmth for your generosity.

Streptococcus wrote:
I said 4 days because If I dont do the fellowship this year, I will move on my current path and not look back.

How much could you have possibly wanted to make the change if you're not willing to wait even one more year to make it? It sounds to me like your artificial "now or never" deadline was a way of talking yourself out of making the change without actually having to own the decision.

HomerJ wrote:

Streptococcus wrote:I said 4 days because If I dont do the fellowship this year, I will move on my current path and not look back.

Why can't you do it next year? Or two years from now?

If I don't do it this year, then I'm just gonna go all in the current route. Be a general pediatrician and be at peace with it, and likely retire earlier. It's an artificial deadline, it's true. But we need deadlines to move on on things and in a week, this whole Peds vs EM dilemma will be gone for good, whatever the final decision is.

ripete wrote:Forgive me, I haven't read the other replies, so I may be repeating.
#1 what's your social situation? do you have a spouse, children, etc? 55k per year simply won't cut it, unless your spouse is earning the extra 250K difference, or at least some reasonable fraction of it thereof.
#2 ok, you love the ER. I get it. How old are you. ER is a young man's game, and you WILL burn out from that also. Yes, you'll do three 12's and then have the rest of the week to do what you want, but just look at the whole picture.
#3 You've got a great practice. You're making over 300K, have great relationships with your patients and have a low liability. I really don't get the trade here. You want to exchange lesser pay, higher liability, and a shorter career for what you have. Please, please someone explain this to me.
#4 OK, I get it. You love the adrenaline rush of the ER. Just beware #2 above, and if you really seek an adrenaline rush, do some extreme sporting.
I WOULD NOT make this move. Period.
P.S. I did internal medicine for three years, then went into anesthesia, which was 3 more years. The difference is that I wasn't earning any money other than a resident's salary, so I was only going to go in one direction. You'll also lose 750K in earnings and in potential investment accumulations.
Just a bad, bad plan. Stick to what you've got. The grass isn't always greener.
OK, sermon finished.

Streptococcus ... The grass is usually NOT greener on the other side. I would suggest you think it through thoroughly before making a jump.

I can empathize with your situation as at mid career I too considered going back and doing an additional sub-specialty residency. In my case, after a decade as a busy academic surgical attending doing a wide variety of general, thoracic, and vascular procedures, I thought my true love and passion was vascular surgery. I interviewed successfully at several programs and entered the Vascular surgery match program. But my spouse was adamantly opposed to our moving or my being away for two or three years as we had young teen age boys she knew needed my presence. Probably luckily (for my still intact family life and current happiness) I decided to pull out of the vascular match a few days before the deadline. In retrospect I am very glad I stayed put and had a very satisfying career doing surgery and teaching surgery residents. As it turned out the big open vascular procedures I'd loved were soon supplanted by endovascular procedures and I came to love lapaparoscopic and thoracoscopic procedures in my own field.

Personally I would not want to become an E.R. physician as I have met very few if any happy middle age or older E.R. physicians. I understand well that true emergencies are exciting and glamorous when young. As a surgeon many times I experienced what a rush it is saving a life through application of knowledge and skill, especially when the patient arrives at the brink of death and you can cheat the grim reaper as by restoring breathing through intubation or cricothyroidotomy, reversing shock by stopping exsananguinating hemorrhage and resuscitating via volume re-expansion, going from a technically "dead" patient in cardiac arrest from pericardial tamponade by pericardiotomy and seeing the heart fill and start to beat (with full patient recovery), etc., etc. and even the pleasure of seeing patients recover from more usual emergencies because of one's interventions. It is hard not to feel personal satisfaction from this.
Yet we are all humans and what seems exciting when we are young and have boundless energy can seem onerous a decade later especially at 3 AM on top of an accumulated sleep deficit especially when by that point you've seen it all and done it all many times before and this time seems like one more in an endless stream. Burnout is a big problem among surgeons and I observe also for E.R. physicians.

In an E.R. setting patient interaction is usually a brief one time event very different from the patient continuity common to Family Practice and Pediatrics. Your sound like you enjoy the social patient / patient family interactions aspect of your current position. I suspect that would be lost in E.R. work.

Look carefully before you leap. Whatever you do, do it with your whole heart.

Grateful1 wrote:Streptococcus ... The grass is usually NOT greener on the other side. I would suggest you think it through thoroughly before making a jump.

I can empathize with your situation as at mid career I too considered going back and doing an additional sub-specialty residency. In my case, after a decade as a busy academic surgical attending doing a wide variety of general, thoracic, and vascular procedures, I thought my true love and passion was vascular surgery. I interviewed successfully at several programs and entered the Vascular surgery match program. But my spouse was adamantly opposed to our moving or my being away for two or three years as we had young teen age boys she knew needed my presence. Probably luckily (for my still intact family life and current happiness) I decided to pull out of the vascular match a few days before the deadline. In retrospect I am very glad I stayed put and had a very satisfying career doing surgery and teaching surgery residents. As it turned out the big open vascular procedures I'd loved were soon supplanted by endovascular procedures and I came to love lapaparoscopic and thoracoscopic procedures in my own field.

Personally I would not want to become an E.R. physician as I have met very few if any happy middle age or older E.R. physicians. I understand well that true emergencies are exciting and glamorous when young. As a surgeon many times I experienced what a rush it is saving a life through application of knowledge and skill, especially when the patient arrives at the brink of death and you can cheat the grim reaper as by restoring breathing through intubation or cricothyroidotomy, reversing shock by stopping exsananguinating hemorrhage and resuscitating via volume re-expansion, going from a technically "dead" patient in cardiac arrest from pericardial tamponade by pericardiotomy and seeing the heart fill and start to beat (with full patient recovery), etc., etc. and even the pleasure of seeing patients recover from more usual emergencies because of one's interventions. It is hard not to feel personal satisfaction from this.
Yet we are all humans and what seems exciting when we are young and have boundless energy can seem onerous a decade later especially at 3 AM on top of an accumulated sleep deficit especially when by that point you've seen it all and done it all many times before and this time seems like one more in an endless stream. Burnout is a big problem among surgeons and I observe also for E.R. physicians.

In an E.R. setting patient interaction is usually a brief one time event very different from the patient continuity common to Family Practice and Pediatrics. Your sound like you enjoy the social patient / patient family interactions aspect of your current position. I suspect that would be lost in E.R. work.

Look carefully before you leap. Whatever you do, do it with your whole heart.

Thank you very much for you thoughtful words. I really appreciate them especially because you went through the same process as me and having a spouse, kids and an already great career, you understand how difficult it can be to make the decision I have to make.

The fact is, to get where I am today, I had to take chances, risk, leap. This is a difficult decision because for the first time in my life I have to ask myself "when do you stop?" when do you stop taking risks in order to climb? when is enough enough? I never had to ask myself that question. My default mode was always to be aggressive, take the big risk-big reward situation. That's how I landed in my current job, which is very very stable with a lot of growth potential.

I find settling a little unsettling, I have to admit it, but at the same time, I also realize that Larry swedroe's asset allocation rules also applies to life: Do I need to take a risk? Can I afford to take the risk? This is the big question. And I also remember Bill Bernstein, who says, when you win the game stop playing. And this is what most physicians in this thread are saying: If as a physician you make >300K, you like your job and you are pretty much your own boss, you can consider to have won that game and you should stop playing.

Streptococcus wrote:Here are the pros for going to fellowship (emergency medicine) /quitting my job[/b]
- I love being a practitioner but I prefer my emergency medicine. So this is a typical case where my career fulfillment requires me to pursue a fellowship, but it may not be a sound financial decision.
- did I say that I love emergency medicine?
- It will be easier for me to work part-time (2 days a week) after I hit my number
- I would be more marketable than a general practitioner

This is an unconvincing pro list. You prefer emergency medicine (ok), you love emergency medicine (great), this fellowship will make it easier for you to work part time later (is that true?), and you'd be more marketable than a general practitioner (this doesn't ring true). You're clearly intelligent and talented, so I highly doubt that you'll have any trouble finding part time work or being marketable regardless of what decision you make. The reality is that you've stumbled upon something new and different that sounds fun. You're probably restless because you're a driven achiever who has reached all your current goals and now you are craving a new challenge. It seems like the success and satisfaction you've had may have come relatively easily/quickly (you are young to have a medical degree, no debt, and a $300k+ income), and you probably presume that any endeavor you tackle will come with similar enjoyable results. Maybe it will, but maybe not.

The problem is that you haven't reached the goal of hitting your "number" - you've just laid the plan for doing so. Now you want to skip ahead to the reward of being able to do whatever you want to do the most without regard for what it pays. That's something you get to do after you have the finances set up. It would be one thing if you currently hate your life and have a once-in-a-lifetime chance to chase your dream, but you "love" being a practitioner. You don't hate your patients, and you just started making the big bucks. These realities seem to all apply to precious few doctors, particularly those so young as you. I would suggest working for at least 5 more years where you are to get the full "reward" (financially and otherwise) out of the practice you've built. If it has to be 8 years, then fine. At that point you can "retire" and do whatever you want, professionally and personally.

In the meantime, you can find other outlets for any urge to be growing and striving. Enjoy watching your investment portfolio grow, for one thing! Take up a few ER shifts, volunteer, take a sabbatical with Doctors without Borders, invest in your relationship with your wife/kids, or take up a new hobby - golf is a never-ending pursuit for improvement, so that could be a great activity for you.

Meg77 wrote:The problem is that you haven't reached the goal of hitting your "number" - you've just laid the plan for doing so. Now you want to skip ahead to the reward of being able to do whatever you want to do the most without regard for what it pays. That's something you get to do after you have the finances set up.

I work in emergency medicine too, but on the other side. I have been a firefighter/paramedic in a large midwestern city for 10 years. I went to podiatry school before dropping out. I married a dentist. When I went to podiatry school, to was a substitute for doing what I REALLY wanted to do, be an ER physician, so I know what you are going through, to a degree.

I will make $130K this year, and when I retire, my pension will be a minimum of 50% of my base salary, which in 2015, will be $98K. FOR THE REST OF MY LIFE. If I hang on, it increases by 2.5% a year for every year I do after 20, maxing out at 75%. I work 91 days a year, not including the OT I do. So I can also quit relatively early, age 50, in ten years, if I so choose.

My gut reaction is to say- stay put. Heed well what the experienced ER doc wrote. We are on the same calls. He just gets even more walk-ins. 80-90% of my job involves chronic, low level baloney that any GP could take care of. He had a seizure but he's now stopped, her blood sugar is high, her blood sugar is low, she hasn't been taking XYZ medications, and now feels sick, they have had stomach pain for 3 days and calls 911 at 3 AM on a Tuesday. I've had people call for a cut so small you couldn't see it, a foot blister, and an STD when the smell became overpowering. True emergent calls are are 2-3 a week. Ones that I can actually make a difference, maybe once or twice a month (Dead is Dead, regardless of how long I do CPR for). And I work in one of the busiest firehouses in the city. I agree that you should take ACLS, PALS, and ATLS and moonlight. If you are making 300K working 5 days a week, work 4 days a week at your current gig, and either moonlight to get your fix, volunteer in an underserved community, or do a few "Doctors Without Borders" trips a year.

I took the plunge, quit the 9-5 job I would have had if I stayed in podiatry school, and pursued my passion in firefighting/paramedicine. It has turned out great. But I was also 22 when I dropped out and 27 when I went to paramedic school, not 40. Itch your scratch with part-time ER work, or volunteering. In my opinion, you will get 80% of the satisfaction and work ten less years. And five of those ten years will be nights, weekends, and holidays because you'll be the low man on the totem pole.

I am an absolute adrenaline junky. If you need to get that fix, buy an old 911 and go to the racetrack. It's golf at 140 MPH.

If you have young children, say under 10 years old, absolutely do not quit your current gig. Going back to a fellowship is basically 3 years of not seeing your kids. It's not fair to them because you are Type A and have difficulty being without a serious challenge for the first time in your life.

Where are all the customers yachts? |
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“The most powerful force in the Universe is compound interest.” -Albert Einstein

Bogleheads,
Thank you for the many many advices that you posted me. I so truly appreciated them and they were of enormous help. In the end, I decided to forgo the fellowship option and embrace the status quo. Here is the reasoning:
1. After a few years of building the practice, now that I am cruising at high altitudes, it would be silly to land and start over again. In fact, the fellowship is a terrible financial decision; maybe a 350K/year mistake for 3 years that will not be recouped in the future, unless I decide to work an extra 3-5 years; I love ER but not that much
2. After soul searching quite a bit, I acknowledged that one should do a fellowship not for lifestyle reasons but as a commitment to a specialty; you should want to do research, academics, and/or clinical practice. I dislike research and academics. The only thing that I like is critical care; to deal with serious illness. As a general pediatrician who attends at risk deliveries and leads codes in the ER, switching to EM was a way to do it than the 2 times a month that I currently do it. But as many ER docs have pointed out on this thread, it is true that serious illnesses are not that common even in the ED and most shifts are about non life threatening conditions. I already deal with critical care as a general peds who deals with sick newborns and admits his own patients. If the fellowship were 1 year, maybe 2, I would consider it for the additional skill set (ultrasound, sedations, more advance airway training, etc. ) that I would acquire and for the board certification but it is not worth a 350K a year pay loss.
3. Also, if I were 10 years younger, with no kids or maybe with only 1 small kid, it would be worth the loss/risk, but at this point, I about 8 more years of working hard after which I'm going to slow down a bit.
In the end, surprisingly, this was probably the most difficult decision I ever made in my life. My spouse was quite surprise that I decided to forgo the fellowship because she expected me to act as I always did, which is to get on my default mode and continue to climb the ladder. But at some point, one has to stop. My whole thought process was written in a piece of paper in case one day I forget all the nuances of my decision.
Again, thank you for your help

For me, financial independence was a life changing mental milestone as it allowed me to take >100% income risks. However, in reality it did not significantly change my day to day activity... I have been lucky enough to be "fishing on the beach" all my life.

As I read your post, it sounded like pediatric ER medicine is your "fishing". If so, I encourage you to follow it... even if it turns out that it is not... then IMHO you should have no regrets but keep searching. I say this in the context that you will clearly not starve while you search:-)

Happy Hunting!

To me pediatric emergency is a passion but it's first of all a mean to something bigger. When I ask myself what I really want in life for self fulfillment I come up with one and the same answer: Time. Time to do the many things that I enjoy doing; Time for my hobbies, family, time to do nothing or to do everything. And I reached the conclusion that working 2 days a week and enjoying 5 days a week of "free" Time is a great deal, a great goal to seek.

if I get there I may not need to retire ever as for me working 2 days a week is optimal indefinitely. To me, the concept of retirement as the end of work derives from the industrial revolution, from jobs that were physically and mentally demanding, unrewarding, very often hazardous to your health. If you are lucky enough to do something that you love and at the same time you have time to enjoy life, why should you ever quit if you are healthy enough to do it?

So Gen peds vs peds EM is part of a journey that seeks Time. I can only enjoy Time if I can have a fulfilling 2 days a week job.

I came late to the party but I found it an interesting discussion and am glad to see that you did not take the fellowship. As I have told countless residents over the years, do a fellowship because you have a real passion for the subspecialty and can't imagine being in your specialty without that additional training. Financially it's a disaster, and probably more so as one gets older.

Your comments about time are very interesting to me-- I'm an anesthesiologist who walked away from a $400k/yr job to a schedule that is exactly what you described-- 2 days/wk. I had roughly $1M invested when I made the switch and felt safe enough in this amount to jump ship. I was also able to stay at the same hospital so there was minimal disruption to my professional life-- I just work less. I'm not even that far out of training but I woke up one day and realized that the irregular hours, stress, and requirement for outside activities such as research and teaching were not worth the salary to me. I work less than half of what I used to, and I earn less than half of what I used to, but I'm more than twice as happy so I consider it a fair trade. My hours are regular, I no longer work in the middle of the night or on weekends, and I've had time to pursue other interests. And, I still am able to save some good money (far less than before but enough for me). I've often commented since my switch that I wish everyone could work part-time because I want others to experience the same amazing effect I've experienced. I'm no longer constantly tired, I'm less crabby, I don't sweat the small stuff, and I'm overall just more content. I wonder what society would be like with a bunch of rested, relaxed individuals...

Anyway, I wish you well in your endeavours and hope that you can reach your goal of having more free time.

For me, financial independence was a life changing mental milestone as it allowed me to take >100% income risks. However, in reality it did not significantly change my day to day activity... I have been lucky enough to be "fishing on the beach" all my life.

As I read your post, it sounded like pediatric ER medicine is your "fishing". If so, I encourage you to follow it... even if it turns out that it is not... then IMHO you should have no regrets but keep searching. I say this in the context that you will clearly not starve while you search:-)

Happy Hunting!

To me pediatric emergency is a passion but it's first of all a mean to something bigger. When I ask myself what I really want in life for self fulfillment I come up with one and the same answer: Time. Time to do the many things that I enjoy doing; Time for my hobbies, family, time to do nothing or to do everything. And I reached the conclusion that working 2 days a week and enjoying 5 days a week of "free" Time is a great deal, a great goal to seek.

if I get there I may not need to retire ever as for me working 2 days a week is optimal indefinitely. To me, the concept of retirement as the end of work derives from the industrial revolution, from jobs that were physically and mentally demanding, unrewarding, very often hazardous to your health. If you are lucky enough to do something that you love and at the same time you have time to enjoy life, why should you ever quit if you are healthy enough to do it?

So Gen peds vs peds EM is part of a journey that seeks Time. I can only enjoy Time if I can have a fulfilling 2 days a week job.

I came late to the party but I found it an interesting discussion and am glad to see that you did not take the fellowship. As I have told countless residents over the years, do a fellowship because you have a real passion for the subspecialty and can't imagine being in your specialty without that additional training. Financially it's a disaster, and probably more so as one gets older.

Your comments about time are very interesting to me-- I'm an anesthesiologist who walked away from a $400k/yr job to a schedule that is exactly what you described-- 2 days/wk. I had roughly $1M invested when I made the switch and felt safe enough in this amount to jump ship. I was also able to stay at the same hospital so there was minimal disruption to my professional life-- I just work less. I'm not even that far out of training but I woke up one day and realized that the irregular hours, stress, and requirement for outside activities such as research and teaching were not worth the salary to me. I work less than half of what I used to, and I earn less than half of what I used to, but I'm more than twice as happy so I consider it a fair trade. My hours are regular, I no longer work in the middle of the night or on weekends, and I've had time to pursue other interests. And, I still am able to save some good money (far less than before but enough for me). I've often commented since my switch that I wish everyone could work part-time because I want others to experience the same amazing effect I've experienced. I'm no longer constantly tired, I'm less crabby, I don't sweat the small stuff, and I'm overall just more content. I wonder what society would be like with a bunch of rested, relaxed individuals...

Anyway, I wish you well in your endeavours and hope that you can reach your goal of having more free time.

Congratulations on your decision.I made a similarly difficult decision five years ago. Like you, I documented my rationale. It has helped me many times when I begin to doubt myself. Five years later, I almost never think about it and I am very happy with my decision.

As one climbs the proverbial ladder to the top, one envisions stretching out at the top of the pinnacle and enjoying the magnificent view.

One colleague shared this perspective long ago, and added the invaluable observation that one never actually reaches the top.

I might put it a bit differently. I don't know if you have climbed any mountains, but there is a certain feeling one experiences at the moment one decides to conclude the brief celebration at the summit, before beginning the climb back down.